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Disease activity-guided dose optimisation of adalimumab and etanercept is a cost-effective strategy compared with non-tapering tight control rheumatoid arthritis care: analyses of the DRESS study
  1. Wietske Kievit1,
  2. Noortje van Herwaarden2,
  3. Frank HJ van den Hoogen2,3,
  4. Ronald F van Vollenhoven4,
  5. Johannes WJ Bijlsma5,
  6. Bart JF van den Bemt6,7,
  7. Aatke van der Maas2,
  8. Alfons A den Broeder2
  1. 1Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
  2. 2Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
  3. 3Department of Rheumatology, Radboud university medical center, Nijmegen, The Netherlands
  4. 4ClinTRID, Karolinska Institute, Stockholm, Sweden
  5. 5Department of Rheumatology & Immunology, Utrecht University Medical Centre, Utrecht, The Netherlands
  6. 6Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
  7. 7Department of Pharmacy, Radboud university medical center, Nijmegen, The Netherlands
  1. Correspondence to Dr Wietske Kievit, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands; wietske.kievit{at}


Background A disease activity-guided dose optimisation strategy of adalimumab or etanercept (TNFi (tumour necrosis factor inhibitors)) has shown to be non-inferior in maintaining disease control in patients with rheumatoid arthritis (RA) compared with usual care. However, the cost-effectiveness of this strategy is still unknown.

Method This is a preplanned cost-effectiveness analysis of the Dose REduction Strategy of Subcutaneous TNF inhibitors (DRESS) study, a randomised controlled, open-label, non-inferiority trial performed in two Dutch rheumatology outpatient clinics. Patients with low disease activity using TNF inhibitors were included. Total healthcare costs were measured and quality adjusted life years (QALY) were based on EQ5D utility scores. Decremental cost-effectiveness analyses were performed using bootstrap analyses; incremental net monetary benefit (iNMB) was used to express cost-effectiveness.

Results 180 patients were included, and 121 were allocated to the dose optimisation strategy and 59 to control. The dose optimisation strategy resulted in a mean cost saving of −€12 280 (95 percentile −€10 502; −€14 104) per patient per 18 months. There is an 84% chance that the dose optimisation strategy results in a QALY loss with a mean QALY loss of −0.02 (−0.07 to 0.02). The decremental cost-effectiveness ratio (DCER) was €390 493 (€5 085 184; dominant) of savings per QALY lost. The mean iNMB was €10 467 (€6553–€14 037). Sensitivity analyses using 30% and 50% lower prices for TNFi remained cost-effective.

Conclusions Disease activity-guided dose optimisation of TNFi results in considerable cost savings while no relevant loss of quality of life was observed. When the minimal QALY loss is compensated with the upper limit of what society is willing to pay or accept in the Netherlands, the net savings are still high.

Trial registration number NTR3216; Post-results.

  • Anti-TNF
  • Rheumatoid Arthritis
  • Economic Evaluations
  • Outcomes research

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  • Handling editor Tore K Kvien

  • Contributors NvH, AAdB, AvdM, BJFvdB, FHJvdH, RFvV and JWJB were involved in the study design. NvH, AAdB, AvdM and FHJvdH were involved in the data collection. WK, NvH and AAdB performed the data analyses. All authors were involved in writing, revising and final approving of the manuscript.

  • Competing interests All authors have completed the ICMJE uniform disclosure form at and declare: JWJB received grants and personal fees from Pfizer and AbbVie, during the conduct of the study; grants and personal fees from Roche, BMS, UCB, outside the submitted work. RFvV received grants from AbbVie, BMS, GSK, Pfizer, Roche, UCB and personal fees from AbbVie, Biotest, BMS, GSK, Janssen, Lilly, Merck, Pfizer, Roche, UCB, Vertex, outside the submitted work.

  • Ethics approval CMO region Arnhem-Nijmegen.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The authors commit to making the relevant anonymised patient level data available on reasonable request.